MicroRNAs as potential circulating biomarkers of drug-induced liver injury: key current and future issues for translation to humans

Drug-induced liver injury (DILI) is a common form of adverse drug reaction seen within the clinic. Sensitive, specific and non-invasive biomarkers of liver toxicity are required to help diagnose hepatotoxicity and also to identify safety liabilities during drug development. Limitations exist in the current gold standard DILI biomarkers: alanine aminotransferase is not liver-specific and therefore gives rise to false-positive signals. Interest has grown in the potential of microRNAs (miRNAs) as biomarkers of DILI. Some miRNAs display remarkable organ specificity, can be measured sensitively and are stable in a wide range of biofluids. However, little is currently known about the mechanisms through which miRNAs are released from cells. Furthermore, a clinically suitable method to measure miRNAs has not yet been developed. This review aims to highlight the current research surrounding these markers and areas in which further work is required to establish these markers within clinical and pre-clinical settings.     

The potential of cytokines as safety biomarkers for drug-induced liver injury

Drug-induced liver injury (DILI) is an event that has a detrimental impact on drug development and patient safety; therefore the identification of novel biomarkers that are both sensitive and specific to the liver would have great benefit. Inflammation is known to be associated with human cases of DILI, and given the role of cytokines in modulating the inflammatory response, changes in cytokine expression patterns certainly show promise as potential biomarkers of DILI. Cytokines are interesting candidates for novel biomarkers as they are relatively accessible (by blood sampling) and accurately quantifiable. In particular, recent interest has developed in mechanism-specific, rather than tissue-specific, biomarkers. However, without fully understanding the role of inflammation in DILI and the role of cytokines in modulating the inflammatory response, cytokines may be limited in their use, being either diagnostic of the type of injury that has occurred and/or prognostic of outcome (recovery from DILI, cirrhosis, acute liver failure). Intracellular components released by damaged hepatocytes, although inaccessible and currently difficult to quantify, may be better biomarkers for the prognosis of severity of injury. In both cases there is a pressing need for the development and validation of assays sensitive enough and with a sufficient dynamic range to detect changes upon drug treatment. Although promising candidates are appearing in the literature, much remains to be done to understand the role of inflammation in DILI and the role that a given cytokine has in the inflammatory cascade associated with DILI before cytokines are viewed as biomarkers for DILI.     

药物性肝损伤的生物标志物及其评价的研究进展

药物性肝损伤是伴随药物使用而出现的主要不良反应,是肝疾病的主要组成部分,目前血清天冬氨酸转氨酶、丙氨酸转氨酶、碱性磷酸酶和总胆红素等传统标志物在药物性肝损伤的预测和诊断中的地位尚无可取代,但近年发现的血清药物-蛋白加合物、嗜酸性粒细胞、乳酸脱氢酶、谷氨酰胺脱氢酶及基因组学生物标志物等多种新的生物标志物对弥补传统生物标志物检测敏感性和特异性的作用也不可忽视。本文结合药物性肝损伤评价现状对传统生物标志物和近年发现的新的肝损伤生物标志物进行概述,为更好地预测和诊断肝损伤、减轻药物性危害提供可能的帮助。     

Zebrafish as model organisms for studying drug-induced liver injury

Drug-induced liver injury (DILI) is a major challenge in clinical medicine and drug development. New models are needed for predicting which potential therapeutic compounds will cause DILI in humans, and new markers and mediators of DILI still need to be identified. This review highlights the strengths and weaknesses of using zebrafish as a high-throughput in vivo model for studying DILI. Although the zebrafish liver architecture is different from that of the mammalian liver, the main physiological processes remain similar. Zebrafish metabolize drugs using similar pathways to those in humans; they possess a wide range of cytochrome P450 enzymes that enable metabolic reactions including hydroxylation, conjugation, oxidation, demethylation and de-ethylation. Following exposure to a range of hepatotoxic drugs, the zebrafish liver develops histological patterns of injury comparable to those of mammalian liver, and biomarkers for liver injury can be quantified in the zebrafish circulation. The zebrafish immune system is similar to that of mammals, but the zebrafish inflammatory response to DILI is not yet defined. In order to quantify DILI in zebrafish, a wide variety of methods can be used, including visual assessment, quantification of serum enzymes and experimental serum biomarkers and scoring of histopathology. With further development, the zebrafish may be a model that complements rodents and may have value for the discovery of new disease pathways and translational biomarkers.     

A novel platform for cancer therapy using extracellular vesicles

Extracellular vesicles (EVs) are nanometer-sized membranous vesicles and are involved in cell-to-cell communication. EVs contain several types of functional molecules, such as proteins, mRNAs, and microRNAs (miRNAs). Over the past several years, EVs have emerged as potential tools for a drug delivery system (DDS) that can target organs or cells. EVs have a function of organ tropism and are naturally occurring from cells. Therefore, EVs have expected as naturally DDSs, which have the organ tropism and a low side effect. Actually, some reports showed that EVs delivered drugs to specific organ. However, despite observed the organ tropism, the mechanisms of organ tropism of EVs are still unclear. Moreover, preservation and efficient collection of EVs are desired to be investigated. Here, we provide an overview of the methods for using EVs as DDSs.     

Metabolomic approaches in the discovery of potential urinary biomarkers of drug-induced liver injury (DILI)

Drug-induced liver injury (DILI) is a major safety issue during drug development, as well as the most common cause for the withdrawal of drugs from the pharmaceutical market. The identification of DILI biomarkers is a labor-intensive area. Conventional biomarkers are not specific and often only appear at significant levels when liver damage is substantial. Therefore, new biomarkers for early identification of hepatotoxicity during the drug discovery process are needed, thus resulting in lower development costs and safer drugs. In this sense, metabolomics has been increasingly playing an important role in the discovery of biomarkers of liver damage, although the characterization of the mechanisms of toxicity induced by xenobiotics remains a huge challenge. These new-generation biomarkers will offer obvious benefits for the pharmaceutical industry, regulatory agencies, as well as a personalized clinical follow-up of patients, upon validation and translation into clinical practice or approval for routine use. This review describes the current status of the metabolomics applied to the early diagnosis and prognosis of DILI and in the discovery of new potential urinary biomarkers of liver injury.     

Application of urine proteomics for biomarker discovery in drug-induced liver injury

The leading cause of hepatic damage is drug-induced liver injury (DILI), for which currently no adequate predictive biomarkers are available. Moreover, for most drugs related to DILI, the mechanisms underlying the adverse reaction have not yet been elucidated. Urinary protein biomarker candidates for DILI have emerged in the past few years and correlate well with clinical studies for serum DILI biomarkers. The goal of this review was to investigate the use of urine as a source of protein biomarkers for drug-induced liver injury. Finally, we discuss some of the current strategies required to advance the field of biomarker discovery for DILI with respect to appropriate clinical biobanking and adequate translational research.     

Is toxicogenomics a more reliable and sensitive biomarker than conventional indicators from rats to predict drug-induced liver injury in humans?

Around 40% of drug-induced liver injury (DILI) cases are not detected in preclinical studies using the conventional indicators. It has been hypothesized that genomic biomarkers will be more sensitive than conventional markers in detecting human hepatotoxicity signals in preclinical studies. For example, it has been hypothesized and demonstrated in some cases that (1) genomic biomarkers from the rat liver can discriminate drug candidates that have a greater or lesser potential to cause DILI in susceptible patients despite no conventional indicators of liver toxicity being observed in preclinical studies, and (2) more sensitive biomarkers for early detection of DILI can be derived from a "subtoxic dose" at which the injury in the liver occurs at the molecular but not the phenotypic level. With a public TGx data set derived from short-term in vivo studies using rats, we divided drugs exhibiting human hepatotoxicity into three groups according to whether elevated alanine aminotransferase (ALT) or total bilirubin (TBL) were observed in the treated rats: (A) The elevation was observed in the treated rats, (B) no elevation was observed for all of the treated rats, and (C) no elevation could be observed at a lower dose and shorter duration but occur when a higher or longer treatment was applied. A control group (D) was comprised of drugs known not to cause human hepatotoxicity and for which no rats exhibited elevated ALT or TBL. We developed classifiers for groups A, B, and C against group D and found that the gene signature from scenario A could achieve 83% accuracy for human hepatotoxicity potential of drugs in a leave-one-compound-out cross-validation process, much higher than scenarios B (average 45%) and C (61%). Furthermore, the signature derived from scenario A exhibited relevance to hepatotoxicity in a pathway-based analysis and performed well on two independent public TGx data sets using different chemical treatments and profiled with different microarray platforms. Our study implied that the human hepatotoxicity potential of a drug can be reasonably assessed using TGx analysis of short-term in vivo studies only if it produces significant elevation of ALT or TBL in the treated rats. The study further revealed that the value of "sensitive" biomarkers derived from scenario C was not promising as expected for DILI assessment using the reported TGx design. The study will facilitate further research to understand the role of genomic biomarkers from rats for assessing human hepatotoxicity.     

药物性肝损伤的肝细胞死亡方式及治疗药物研究进展

药物性肝损伤（DILI）是临床常见的肝损伤类型,是严重的药物不良反应之一。细胞死亡是DILI的重要特征,药物可通过诱导内质网应激和激活死亡受体等方式激活凋亡通路,诱导肝细胞凋亡或坏死,诱发肝损伤。除凋亡和坏死外,DILI过程中还伴随着自噬、焦亡和铁死亡。自噬可以清除受损的蛋白质以及细胞器,是肝细胞存活的重要机制,但也可能诱导肝细胞死亡。焦亡和铁死亡是最近发现的细胞死亡方式,其在DILI中的作用尚未完全阐明。阻断肝细胞死亡通路,是治疗DILI的重要手段。水飞蓟素、柚皮素、人参皂苷等可以抑制肝细胞死亡通路,是DILI的潜在治疗药。针对不同细胞死亡方式的机制和特点,研究改善肝细胞死亡的药物对治疗DILI具有重要意义。总结了DILI中肝细胞死亡的机制,并论述了潜在的药物治疗,旨在为DILI的治疗提供参考。     

Drug-induced liver injury: a summary of recent advances

INTRODUCTION: The knowledge base of drug-induced liver injury (DILI) continues to grow each year as additional drugs are identified as hepatotoxins. There is still a need to improve our ability to predict and diagnose DILI in the preclinical and post-approval settings. AREAS COVERED: This article presents the new and updated DILI registries for 2010, including the latest information on the causes and outcomes of non-acetaminophen DILI cases in the US Acute Liver Failure Study Group database. As DILI is still largely a diagnosis of exclusion, it is appropriate that causality assessment instruments are again the subject of considerable discussion. EXPERT OPINION: DILI research remains extremely active including studies aimed at being better able to identify causative agents, utilize potential biomarkers, predict who is at greatest risk of injury and manage outcomes. With respect to identifying DILI risk factors at the genetic level, the field is rapidly approaching the day where 'personalized medicine' (based on pharmacogenomics) will become a reality. A large single-center series from India reminds us that geography can influence the drugs responsible for liver injury; however, Hy's law remains universal. As our DILI knowledge continues to grow, it remains essential to keep abreast of the important changes reported each year.     

药物导致肝损伤、药物处置及其代谢产物分析(英文)

药物导致肝损伤是药物研发失败和上市药退市的一个主要原因。药物导致肝损伤的频发跟肝生理功能密切相关,因为大部分药物分子在体内的消除依赖于药物代谢或胆汁排泄的肝清除。虽然不少发病机制已有广泛的研究,但是大部分与药物导致肝损伤相关的机制仍然未明确。从这个意义上讲,代谢组学将成为研究药物导致肝损伤强有力的手段以有助于更好地了解其机制并进行相关生物标志物的鉴定。     

Cell based approaches for evaluation of drug-induced liver injury

An improved understanding of mechanisms that underlie drug-induced liver injury (DILI) is required to enable design of drugs that have minimal potential to cause this adverse reaction in man. Available evidence suggests DILI arises in susceptible patients because of an imbalance between chemical insults (which are an inherent property of certain drugs and/or their metabolites) and the ability of the liver to mount compensatory/adaptive responses. In vivo safety testing in pre-clinical species ensures that drugs which enter clinical trials do not cause reproducible and dose-dependent liver injury in man, but is of limited value for exploration of underlying mechanisms and does not assess potential to cause rare idiosyncratic DILI. This review highlights the value that can be gained from in vitro studies using cultured hepatocytes and also hepatocyte-derived cell lines transfected with individual human cytochrome P450 (CYP450) isoforms. We have evaluated a range of mechanisms and endpoints (cell necrosis, mitochondrial injury, inhibition of biliary transporters and metabolite-mediated toxicity) using these model systems. Our data indicate that multiple mechanisms are likely to be involved in development of idiosyncratic DILI in man caused by numerous drugs, e.g. the anticonvulsant chlorpromazine.     

Development of a cell-based assay system considering drug metabolism and immune- and inflammatory-related factors for the risk assessment of drug-induced liver injury

Drug-induced liver injury (DILI) is a major safety concern in drug development and clinical pharmacotherapy. However, prediction of DILI is difficult because the underlying mechanisms are not fully understood. To establish a novel cell-based screening system to suggest drugs with hepatotoxic potential in preclinical drug development, comprehensive gene expression analyses during in vivo DILI are necessary. Using in vivo mouse DILI models and 4 sets of hepatotoxic positive and non-hepatotoxic drugs, we found that the hepatic mRNA levels of S100A8; S100A9; “NATCH, LRR, and pyrin domain-containing protein 3” (NALP3); interleukin (IL)-1β; and the receptor for advanced glycation endproducts (RAGE) were commonly increased in hepatotoxic drug-administered mice compared to non-hepatotoxic drug-administered mice. To clarify whether these 5 in vivo biomarkers can be applied to a cell-based screening system, we adapted human liver microsomes (HLM) in the presence of NADPH to assess the metabolic activation reaction, and we also adapted human monocytic leukemia cells HL-60, K562, KG-1 and THP-1 to assess the effects on mRNA expression of immune- and inflammatory-related factors. We investigated 30 clinical drugs with different safety profiles with regard to DILI and found that the total sum score of gene expression levels of S100A8, S100A9, RAGE, NALP3 and IL-1β mRNA in HL-60 or K562 cells incubated with HLM, could identify drugs at high risk for hepatotoxicity. We proposed the use of the total sum score of gene expression level for assessing metabolic activation by drug-metabolizing enzymes and immune- and inflammatory-related factors for the risk assessment of DILI in preclinical drug development.     

Identification of urinary microRNA profiles in rats that may diagnose hepatotoxicity

Circulating microRNAs (miRNAs) have emerged as novel noninvasive biomarkers for several diseases and other types of tissue injury. This study tested the hypothesis that changes in the levels of urinary miRNAs correlate with liver injury induced by hepatotoxicants. Sprague-Dawley rats were administered acetaminophen (APAP) or carbon tetrachloride (CCl(4)) and one nonhepatotoxicant (penicillin/PCN). Urine samples were collected over a 24 h period after a single oral dose of APAP (1250 mg/kg), CCl(4) (2000 mg/kg), or PCN (2400 mg/kg). APAP and CCl(4) induced liver injury based upon increased serum alanine and aspartate aminotransferase levels and histopathological findings, including liver necrosis. APAP and CCl(4) both significantly increased the urinary levels of 44 and 28 miRNAs, respectively. In addition, 10 of the increased miRNAs were in common between APAP and CCl(4). In contrast, PCN caused a slight decrease of a different nonoverlapping set of urinary miRNAs. Cluster analysis revealed a distinct urinary miRNA pattern from the hepatotoxicant-treated groups when compared with vehicle controls and PCN. Analysis of hepatic miRNA levels suggested that the liver was the source of the increased urinary miRNAs after APAP exposure; however, the results from CCl(4) were equivocal. Computational analysis was used to predict target genes of the 10 shared hepatotoxicant-induced miRNAs. Liver gene expression profiling using whole genome microarrays identified eight putative miRNA target genes that were significantly altered in the liver of APAP- and CCl(4)-treated animals. In conclusion, the patterns of urinary miRNA may hold promise as biomarkers of hepatotoxicant-induced liver injury.     

Mechanism of exacerbative effect of progesterone on drug-induced liver injury

Drug-induced liver injury (DILI) is a major safety concern in drug development and clinical drug therapy. However, the underlying mechanism of DILI is little known. It is generally believed that women exhibit worse outcomes from DILI than men. Recently, we found that pretreatment of mice with estradiol attenuated halothane (HAL)-induced liver injury, whereas pretreatment with progesterone exacerbated it in female mice. To investigate the mechanism of sex difference of DILI, we focused on progesterone in this study. We found the exacerbating effect of progesterone in thioacetamide (TA), α-naphthylisothiocyanate, and dicloxacillin-induced liver injury only in female mice. Higher number of myeloperoxidase-positive mononuclear cells infiltrated into the liver and increased levels of Chemokine (C-X-C motif) ligand 1 and 2 (CXCL1 and CXCL2) and intercellular adhesion molecule-1 in the liver were observed. Interestingly, CXCL1 was slightly increased by progesterone pretreatment alone. Progesterone pretreatment increased the extracellular signal-regulated kinase (ERK) phosphorylation in HAL-induced liver injury. Pretreatment with U0126 (ERK inhibitor) significantly suppressed the exacerbating effect of progesterone and the expression of inflammatory mediators. In addition, pretreatment with gadolinium chloride (GdCl(3): inhibitor of Kupffer cells) significantly suppressed the exacerbating effect of progesterone pretreatment and the expression of inflammatory mediators. Moreover, posttreatment of RU486 (progesterone receptor antagonist) 1 h after the HAL or TA administration ameliorated the HAL- or TA-induced liver injury, respectively, in female mice. In conclusion, progesterone exacerbated the immune-mediated hepatotoxic responses in DILI via Kupffer cells and ERK pathway. The inhibition of progesterone receptor and decrease of the immune response may have important therapeutic implications in DILI.     

药物引起的肝损伤发病机制研究进展

药物性肝损伤(drug-induced liver injury, DILI)是由药物或其代谢产物乃至辅料所引起的肝损伤,是目前临床上常见的药品不良反应之一。药物性肝损伤在我国的发生率偏高,仅次于病毒性肝炎和脂肪性肝病。在欧美,药物性肝损伤是引发肝衰竭的主要原因。尽管人们早已意识到药物性肝损伤的危害,但由于其病因复杂,临床表现不具有特异性,诊断标记物特异性不强,导致药物性肝损伤患者常常无法及时被确诊,最终发展为肝衰竭甚至死亡。已知目前有超过1 100种药物可以在不同程度上引起肝损伤。因此,本文主要总结了不同类型药物诱发肝损伤的不同作用机制,为日后药物性肝损伤的预防和治疗提供了一定的理论基础。     

Incidence of drug-induced liver injury in medical inpatients

Objectives Drug-induced liver injury (DILI) is a common concern. However, data on DILI epidemiology in inpatients are sparse.Methods To investigate the incidence of DILI, we screened all patients in the pharmacoepidemiological inpatient database according to the CIOMS (Council for International Organisation of Medical Science) criteria, which consist of the evaluation of some clinical chemistry laboratory liver parameters (CIOMS laboratory criteria) and the exclusion of any disease-related causes for the liver injury. Thus, only cases with probable or certain causality according to the World Health Organization criteria were included.Results Among a total of 6383 patients, liver parameters were determined in 4610, and 489 among them fulfilled the CIOMS laboratory criteria. However, 401 patients had to be excluded because of disease-related liver injury and, thus, the study cohort consisted of 4209 patients at risk for DILI. Among a total of 88 DILI cases, 31 had no documented normal baseline liver parameters and, thus, represented prevalent cases. The remaining 57 represented incident DILI cases. Thus, the incidence of DILI was 1.4% (95% CI 1.0, 1.7). The drug classes most frequently causing DILI were heparins, antibacterials, tuberculostatics and antineoplastic agents. Among those, antineoplastic agents and tuberculostatics showed the highest incidence. Liver injury was not mentioned among the diagnoses or in the physicians discharge letter in about 52–68% of all cases.Conclusion Approximately 1 in 100 patients develops DILI during hospitalisation in a department of medicine. Incidences of DILI were highest for antineoplastic agents and tuberculostatics. DILI is frequently missed and, therefore, DILI detection by diagnoses will result in misleadingly low incidence rates.     

Contributions of caspase-8 and -9 to liver injury from CYP2E1-produced metabolites of halogenated hydrocarbons

1.?Drug-induced liver injury is difficult to predict at the pre-clinical stage. This study aimed to clarify the roles of caspase-8 and -9 in CYP2E1 metabolite-induced liver injury in both rats and cell cultures in vitro treated with carbon tetrachloride (CCl₄), halothane or sevoflurane. The human hepatocarcinoma functional liver cell line was maintained in 3-dimensional culture alone or in co-culture with human acute monocytic leukemia cells.

2.?In vivo, laboratory indices of liver dysfunction and histology were normal after administration of sevoflurane. CCl₄ treatment increased blood AST/ALT levels, liver caspase-3 and -9 activities and liver malondialdehyde, accompanied by centrilobular hepatocyte necrosis. Halothane increased AST/ALT levels, caspase-3 and -8 activities (but not malondialdehyde) concomitant with widespread hepatotoxicity. In vitro, CCl₄ treatment increased caspase-9 activity and decreased both mitochondrial membrane potential (MMP) and cell viability. In co-culture, halothane increased caspase-8 activity and decreased MMP and cellular viability. There were no toxic responses in CYP2E1 knockdown in monoculture and co-culture.

3.?CYP2E1-inducing compounds play a pivotal role in halogenated hydrocarbon toxicity.

4.?Changes in hepatocyte caspase-8 and -9 activities could be novel biomarkers of metabolites causing DILI, and in pre-clinical development of new pharmaceuticals can predict nascent DILI in the clinical stage.     

Mitochondrial abnormalities--a link to idiosyncratic drug hepatotoxicity?

Idiosyncratic drug-induced liver injury (DILI) is a major clinical problem and poses a considerable challenge for drug development as an increasing number of successfully launched drugs or new potential drugs have been implicated in causing DILI in susceptible patient subsets. Although the incidence for a particular drug is very low (yet grossly underestimated), the outcome of DILI can be serious. Unfortunately, prediction has remained poor (both for patients at risk and for new chemical entities). The underlying mechanisms and the determinants of susceptibility have largely remained ill-defined. The aim of this review is to provide both clinical and experimental evidence for a major role of mitochondria both as a target of drugs causing idiosyncratic DILI and as mediators of delayed liver injury. We develop a unifying hypothesis that involves underlying genetic or acquired mitochondrial abnormalities as a major determinant of susceptibility for a number of drugs that target mitochondria and cause DILI. The mitochondrial hypothesis, implying gradually accumulating and initially silent mitochondrial injury in heteroplasmic cells which reaches a critical threshold and abruptly triggers liver injury, is consistent with the findings that typically idiosyncratic DILI is delayed (by weeks or months), that increasing age and female gender are risk factors and that these drugs are targeted to the liver and clearly exhibit a mitochondrial hazard in vitro and in vivo. New animal models (e.g., the Sod2(+/-) mouse) provide supporting evidence for this concept. However, genetic analyses of DILI patient samples are needed to ultimately provide the proof-of-concept.